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Documentos de Profesional
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YO U T H R E S E A R C H W O R K I N G PA P E R S E R I E S
ACKNOWLEDGMENTS
Douglas Kirby, B.A. Laris, and Lori Rolleri work for ETR Associates, a research organization
that has studied sex and HIV education in schools for many years.
The authors appreciate input and review comments from Karin Coyle of ETR Associates; Ralph
DiClemente of the Rollins School of Public Health of Emory University; John Jemmott of the Annenberg School of Communication at the University of Pennsylvania; Angela Obassi of Liverpool
School of Tropical Medicine; David Ross of the London School of Hygiene and Tropical Medicine; Carmen Cuthbertson, Cindy Waszak Geary, JoAnn Lewis, Hally Mahler, Tonya Nyagiro,
and Jane Schueller of Family Health International (FHI); and Shanti Conly, Sarah Harbison, and
Pam Mandel of the U.S. Agency for International Development (USAID). Production assistance
came from William Finger (editing), Kerry Wright Aradhya (copyediting), Marina McCune and
Lucy Harber (layout), and Karen Dickerson (print coordination).
YouthNet is a ve-year program funded by USAID to improve reproductive health and prevent
HIV among young people. The YouthNet team is led by FHI and includes CARE USA and RTI
International. This publication is funded through the USAID Cooperative Agreement with FHI for
YouthNet, No. GPH-A-00-01-00013-00. The information contained in the publication does not
necessarily reect FHI or USAID policies.
CONTENTS
Executive Summary
Introduction
Methods
Results
11
11
Impact of Programs on Sexual Risk Behaviors and Pregnancy and STI Rates
15
21
26
Discussion
38
Recommendations
41
43
Endnotes
44
13
17
20
24
27
EXECUTIVE SUMMARY
Sex and HIV education programs that are based on a written curriculum and that are implemented
among groups of youth in school, clinic, or community settings are a promising type of intervention to reduce adolescent sexual risk behaviors. This paper summarizes a review of 83 evaluations
of such programs in developing and developed countries. The programs typically focused on
pregnancy or HIV/STI prevention behaviors, not on broader issues of sexuality such as developmental stages, gender roles, or romantic relationships.
The review analyzed the impact programs had on sexual risk-taking behaviors among young
people. It addressed two primary research questions:
1) What are the effects, if any, of curriculum-based sex and HIV education programs on sexual
risk behaviors, STI and pregnancy rates, and mediating factors such as knowledge and attitudes
that affect those behaviors?
2) What are the common characteristics of the curricula-based programs that were effective in
changing sexual risk behaviors?
The methods used in this review included three primary activities: 1) comprehensively searching
for and retrieving all studies meeting specied criteria, 2) coding all the results of those studies, and
3) conducting a content analysis of 19 curricula that were clearly effective at changing behavior.
Impact of Programs on Sexual Risk Behaviors and Pregnancy and STI Rates. The 83 studies
generally reported on one or more of six aspects of sexual behavior: initiation of sex, frequency
of sex, number of sexual partners, condom use, contraceptive use in general, and composite measures of sexual risk-taking. A few studies reported on pregnancy and STI rates.
Initiation of Sex. Of the 52 studies that measured impact on this behavior, 22 (42 percent) found
that the programs signicantly delayed the initiation of sex among one or more groups for at
least six months, 29 (55 percent) found no signicant impact, and one (in the United States)
found the program hastened the initiation of sex.
Frequency of Sex. Of the 31 studies that measured impact on frequency, nine (29 percent) reduced the frequency, 19 (61 percent) found no signicant change in frequency, and three (all in
developed countries) found increased frequency among any major groups at any point in time.
Number of Sexual Partners. Of 34 studies measuring this factor, 12 (35 percent) found a decrease in the number of sexual partners, while 21 (62 percent) found no signicant impact.
Condom Use. Of the 54 studies measuring program impact on condom use, almost half (48
percent) showed increased condom use; none found decreased condom use.
Contraceptive Use in General. Of the 15 studies measuring impact, six showed increased
contraceptive use, eight showed no impact, and one (in the United States) showed decreased
contraceptive use.
Sexual Risk Taking. Some studies (28) developed composite measures of sexual activity and
condom use (e.g., frequency of sex without condoms). Half of them found signicantly reduced
sexual risk-taking. None of them found increased sexual risk-taking.
Pregnancy Rates. Of the 13 studies that measured pregnancy rates, three found signicant positive effects, nine found insignicant effects, and one (in the United States) found signicant
negative effects.
STI Rates. Of the 10 studies that measured impact on STI rates, two found a positive impact, six
found no signicant impact, and two found a negative impact.
Overall, these results strongly indicate that these programs were far more likely to have a positive impact on behavior than a negative impact. Two-thirds (65 percent) of the studies found a
signicant positive impact on one or more of these sexual behaviors or outcomes, while only 7
percent found a signicant negative impact. One-third (33 percent) of the programs had a positive
impact on two or more behaviors or outcomes. Furthermore, some of these programs had positive impacts for two or three years or more. In general, the patterns of ndings for all the studies
were similar in both developing and developed countries. They were effective with both lowand middle-income youth, in both rural and urban areas, with girls and boys, with different age
groups, and in school, clinic, and community settings.
A review of replication studies of four different curricula in the United States revealed that curricula did have similar positive behavioral effects when they were replicated, provided all activities
were implemented as designed in the same type of setting and with similar populations of youth.
When many activities were omitted or the setting was changed, the curricula were less likely to
have a positive effect.
Impact of Programs on Mediating Factors for Sexual Risk Behaviors. The studies reported on
various mediating factors that contribute to the behavior changes, such as knowledge, perceived
risk, values and attitudes, perception of peer norms, self-efcacy and skills, and others. Most
programs increased knowledge about HIV, STIs, and pregnancy (including methods of preventing STI/HIV and pregnancy). Half of the 16 studies that measured impact on perceived HIV
risk were effective at increasing this perceived risk. More than 60 percent of the many studies
measuring impact on values and attitudes regarding any sexual topic were effective in improving
the measured values and attitudes. More than 40 percent of the 29 studies that measured impact
on perceived peer sexual behavior and norms signicantly improved these perceptions. More
than half of those studies that measured impact on self-efcacy to refuse unwanted sex improved
that self-efcacy, and more than two-thirds increased self-efcacy to use condoms. Regarding
changing motivations, 10 of 16 programs increased motivation or intention to abstain from sex or
restrict the number of sex partners, and 10 of 14 programs increased intention to use a condom.
Eight of 11 programs increased communication with parents or other adults about sex, condoms,
or contraception.
Thus, the evidence was strong that many programs had positive effects on relevant knowledge,
awareness of risk, values and attitudes, self-efcacy, and intentions the very factors specied by
many psychosocial theories as being the determinants of behavior. Furthermore, all of these factors
have been demonstrated empirically to be related to their respective sexual behaviors. Thus, it appears
highly likely that changes in these factors contributed to the changes in sexual risk-taking behaviors.
Characteristics of the Curriculum-Based Programs that Had Impact. The analysis of these
effective curricula led to the identication of 17 common characteristics of the curricula and
their implementation. The large majority of the effective programs incorporated most of the 17
characteristics of successful curriculum-based programs identied in this analysis. Also, programs
that incorporated these characteristics were much more likely to change behavior positively than
programs that did not incorporate many of these characteristics. Five of the 17 characterisctics
involve the development of the curriculum; eight involve the curriculum itself; and four describe
the implementation of the curriculum.
Developing the Curricula. The development teams involved multiple people with varied backgrounds, used a logic model approach that specied health goals and other details, assessed
relevant needs and assets of the target groups, designed activities consistent with community
values and available resources, and pilot-tested the program.
Curricula Content. Effective curricula commonly created a safe environment for youth, focused
on clear goals of preventing HIV/STI and/or pregnancy, focused on specic behaviors leading to these health goals and gave a clear message about those behaviors, addressed psychosocial risk and protective factors affecting those sexual behaviors, included multiple activities
to change the targeted risk and protective factors, employed instructionally sound teaching
methods that actively involved the participants and helped them personalize the information,
employed appropriate activities and messages (for participants culture, age, sexual experience),
and covered topics in a logical sequence.
Implementation of the Curricula. When implementing curricula, effective programs commonly
selected and trained educators with desired characteristics, secured at least minimal support from
authorities, recruited youth if necessary, and implemented virtually all activities as designed.
3
Recommendations
The results and discussion led to the programmatic and research recommendations that follow.
Programmatic
Communities should implement curriculum-based sex and HIV education programs, preferably
those proven to be effective with similar populations or those incorporating as many of the effective
curriculum characteristics as possible.
Organizations developing their own curricula should follow the ve characteristics for developing effective curricula and incorporate the eight content characteristics.
Organizations should follow the ve characteristics for implementing effective curricula.
Programs may have their greatest impact in areas where issues of pregnancy and HIV/STIs are
most salient. Thus, while programs should reach all youth, they should be especially certain to
reach high-risk youth.
Schools and other groups should provide adequate time and resources for these programs to be
implemented.
Organizations should encourage research to develop and evaluate programs that may be even
more effective than current programs.
Communities should not rely solely on these programs to address problems of HIV, other STIs,
and pregnancy but should view them as an important component in a larger initiative that can
reduce sexual risk-taking behavior to some degree.
Research
More rigorous studies of promising programs should be conducted in developing countries.
Evaluations can and should use randomized experimental designs.
Sample sizes should be sufciently large to have adequate statistical power for important statistical analyses, including those among sub-groups.
Laboratory tests rather than self-reported data should be used for measuring pregnancy and STI
rates, whenever possible.
Statistical analyses should assess program effect on mediating factors and the impact of these
factors on behaviors.
Researchers should determine which mediating factors are most important across cultures and
then measure these more consistently so that studies can be compared more easily.
Published results of evaluations should provide more complete descriptions of their programs.
INTRODUCTION
Sex and HIV education programs that are based on a written curriculum and that are implemented
among groups of youth in schools, clinics, or other community settings are a promising type of
intervention for reducing adolescent sexual risk-taking behaviors.
This paper summarizes a review of 83 evaluations of such programs in developing and developed
countries. The programs typically focused on pregnancy or HIV/sexually transmitted infection
(STI) prevention behaviors, not on broader issues of sexuality such as developmental stages, gender roles, or romantic relationships. Thus, in this report, the term sex education is used to refer
to programs focusing on pregnancy or HIV/STI prevention; this differs from sexuality education, which may encompass many more topics. It is also important to distinguish clearly from the
outset that this paper is a review of research studies measuring the impact of programs, not an
evaluation of the programs themselves.
Sex and HIV education programs are commonly implemented in schools, which offer a place
to reach large numbers of youth on a regular basis. Most youth who attend school do so before
they initiate sex, and some are enrolled in school when they do initiate sex. Schools are designed
and structured to teach both knowledge and skills. Thus, with appropriate training, teachers can
implement these programs. If the programs are effective, ministries of education can facilitate
their replication throughout their countries.
Since not all youth are in school when they initiate sex, reaching youth who are out-of-school is
also important. Throughout the world, curriculum-based sex and HIV education programs have
been implemented in clinics, youth-serving agencies, housing projects, faith communities, community centers, juvenile detention centers, and elsewhere. Notably, some programs have been
found to reduce sexual risk-taking behaviors when implemented in both school and community
settings with only minor modications of the curricula.1
Consequently, public health authorities and policy-makers may seriously consider curriculumbased programs for school, clinic, and community settings as a major component of their strategy
for achieving the United Nations General Assembly Special Session (UNGASS) goals for HIV
prevention among youth and other goals for prevention of other STIs and unintended pregnancy.
Numerous, well-conducted studies have demonstrated that sex and HIV education programs can
increase knowledge about how to avoid HIV/STIs and unintended pregnancy. However, to actually reduce rates of HIV/STIs and unintended pregnancy, programs must change behavior, and the
evidence for the impact of these programs on behavior has been less clear. Previous reviews of
the impact of sex and HIV education programs on behavior have typically focused on a particular
geographical area (e.g., the United States or sub-Saharan Africa), are now somewhat dated,2 or
have not analyzed the curricula of the programs in depth. Previous suggestions of key characteristics of effective programs are now more than 10 years old and are limited to the United States.3
In 2004-2005, researchers at ETR Associates, working through Family Health International/
YouthNet, conducted a review of existing evaluations of sex and HIV education programs in
developing and developed countries. The review analyzed the impact the programs had on sexual
risk behavior among young people. It addressed two primary research questions:
5
1) What are the effects, if any, of curriculum-based sex and HIV education programs on sexual
risk behaviors, STI and pregnancy rates, and mediating factors such as knowledge and attitudes
that affect those behaviors?
2) What are the common characteristics of the curricula-based programs that were effective in
changing sexual risk behaviors?
Studies from both developed and developing countries were included in the analysis to have a
sufciently large data base of studies from which to draw conclusions, particularly regarding
common characteristics of effective programs. A longer version of this report with more tables is
available on the FHI Web site under the YouthNet publications page, including one-page summaries of each of the studies evaluated.
METHODS
This review is composed of two components that follow from the two research questions identied above. The rst is a review and analysis of studies evaluating the impact of various curriculum-based programs. The second is a synthesis of the common characteristics of curricula found
to be effective in these studies. The methods for accomplishing both these tasks are described in
this section.
on sexual initiation, the sample was restricted to those who were sexually inexperienced at baseline. In other studies, data were analyzed separately by sex or by age. Because some underpowered studies did nd statistically signicant program effects, no rule was made to exclude them
from the review.
Although nearly all of the effective curricula incorporated nearly all of the effective characteristics,
and although curricula with nearly all of the characteristics were highly likely to be effective, having
most of the 17 characteristics present in a curriculum did not totally ensure signicant changes in
reported behavior. A few programs with curricula that incorporated many of the characteristics
failed to have a signicant impact on sexual behavior because their sample sizes were too small,
they failed to follow study participants for sufcient lengths of time to observe delay in sex, their
measurement of important outcome behaviors was poor, or their control groups received different
but nevertheless potentially effective programs. Some programs may not have had a measured
impact because they were not implemented as designed (e.g., the 12 studies that described implementation problems of varying degrees of severity).
Also, a few curricula that did not appear to incorporate characteristics commonly believed to be
important nevertheless had a positive impact. This could have been because the curricula were
poorly written (e.g., were simply broad outlines) and did not capture well what really happened
in the classroom. In addition, some seemingly weak programs (as well as strong programs) may
have had signicant positive effects simply by chance because of the large number of signicance
tests conducted. Finally, in some cases, the published articles provided too little information about
the intervention, the targeted population, or the evaluation methods to determine why programs
did or did not have an impact.
10
RESULTS
The results are divided into four sections:
1. Characteristics of the studies reviewed
2. Impact of programs on sexual risk behaviors and pregnancy and STI rates
3. Impact of programs on mediating factors for sexual risk behaviors
4. Characteristics of the curricula-based programs that had positive impact
two to 15 hours. But 11 percent included only one session, and 4 percent lasted an hour or less. In
sharp contrast, 22 percent had 16 or more sessions, with 26 percent lasting 16 or more hours.
Regarding methodological characteristics, about half of the studies employed an experimental
design with random assignment of individual youth, classrooms of youth, or entire schools or
communities, while the remaining half used a quasi-experimental design. Nearly 90 percent of the
studies used a cohort design in which they linked baseline and follow-up survey data, while the
others used unmatched cross-sectional surveys. To measure sexual and contraceptive behavior, all
relied on self-reports. While such data are generally believed to be reasonably reliable and valid
in developed countries,5 they may be less reliable and valid in developing countries where youth
may be less accustomed to talking about sex and answering survey questions about personal
behavior.6
Only 23 studies measured impact on pregnancy or STI rates, and of these, only nine used laboratory tests to measure these health outcomes. More than half (59 percent) of the studies measured
impact for at least a year or longer, while 22 percent measured impact for two years or longer.
Compared to past reviews, this review found large percentages of studies that used experimental
designs, used a cohort design, and measured long-term impact on behavior. These changes and
improvements in areas such as statistical analyses demonstrate that standards are becoming more
rigorous.
Many of these studies or the published articles had important limitations. For example, few
described their respective programs adequately; none studied programs for youth engaging in
same-sex behavior; some had problems with implementation; a few had relatively weak quasiexperimental designs; an unknown number had measurement problems; many were statistically
underpowered; most did not adjust for multiple tests of signicance; few measured impact on
either STI or pregnancy rates; and still fewer measured impact on STI or pregnancy rates with
biomarkers. Also, there are inherent biases that affect the publication of studies. Researchers are
more likely to try to publish articles if positive results support their theories and programs and
journals are more likely to accept articles for publication if results are positive.
12
Percent
52%
17
31
7%
93
83%
17
90%
10
11%
26
24
17
11
11
4%
23
22
26
14
7
5
90%
10
51%
49
* The sample sizes change among the study characteristics, because not all studies reported every characteristic.
Table continues on page 14
13
Characteristics
Survey design (N=83)
Matched cohort
Unmatched cross-sectional
Behaviors measured (N=83)
Sexual behavior only (e.g., delay in sex,
number of partners, frequency of sex)
Condom or contraceptive use only
Both sexual behavior and condom or
contraceptive use
Percent
88%
12
8%
4
88
69%
31%
50%
50%
11%
26
6
16
16
13
4
9
13%
30
21
16
16
5
Sex (N=77)
Male
Female
Mixed male and female
7%
9
84
22%
57
22
**Studies used means, medians, and ranges to describe age. In this table, the mean was used if available, the median was
used if the mean was not available, and the midpoint of the range was used if neither the mean nor median was available.
14
2. Impact of Programs on Sexual Risk Behaviors and Pregnancy and STI Rates
The 83 studies reviewed generally reported on six aspects of sexual behavior: initiation of sex,
frequency of sex, number of sexual partners, condom use, contraceptive use in general, and sexual
risk-taking behaviors. A few studies, most in developed countries, reported on pregnancy and
STI rates. The sections that follow discuss each of these areas, based on the data shown in Table 2
(see page 17). Because FHI/YouthNet works primarily in developing countries, the data for the 18
developing countries are shown in a separate Table 3 (see page 20). Annex 1 contains a full list of
references for these studies. (A similar table is not presented for the 65 developed country studies
reviewed.)
Initiation of Sex
An important measure of sexual activity is timing of initiation of sex. The studies reviewed
demonstrate that a substantial percentage of programs delayed the initiation of sex and only one
program hastened the initiation. Of the 52 studies that measured impact on the initiation of sex,
22 (42 percent) found that the programs signicantly delayed the initiation of sex among one or
more groups for at least six months, 29 (55 percent) found no signicant impact, and one (in the
United States) found the program was associated with earlier initiation of sex. Among developing
countries, six out of 14 programs delayed the initiation of sex; among developed countries, 16 out
of 38 did so. Roughly equal percentages of programs were effective in school, clinic, and community settings. Programs were also effective with both males and females and with all three age
groups.
Frequency of Sex
A second measure of sexual activity is the frequency of sex during a specied period of time (e.g.,
three months prior to the survey). This includes not having sex or being abstinent. This measure
is important for both pregnancy and STI prevention. In general, programs did not increase
frequency of sex and some reduced the frequency. Of the 31 studies that measured impact of
programs on frequency, nine (29 percent) found reduced frequency, 19 (61 percent) found no
signicant change, and three (all in developed countries) found increased frequency among any
major groups at any point in time. Both developing and developed countries had programs that
signicantly reduced the frequency of sex. Programs were effective on this measure in school,
clinic, and community settings, among both males and females, and with all three age groups.
are relatively uncommon events. Given that only ve of the 13 studies measuring impact on
pregnancy had sample sizes greater than 2,000 and given that only two of the 11 studies measuring impact on STI rates had sample sizes greater than 2,000, the failure of these results to provide
many statistically signicant results does not necessarily mean that the programs did not have a
programmatically meaningful impact on pregnancy or STI rates.
Developed Country
Studies
N=65
Total
N=83
Outcome
N*
Neg
NS
Pos
Neg
NS
Pos
Neg
NS
Pos
52
21
16
29
22
31
16
19
34
16
21
12
54
23
19
28
26
15
28
12
14
14
14
Reduce pregnancy:
Self-reports
Reduce pregnancy:
Laboratory tests
Reduce STIs:
Self-reports
Reduce STIs:
Laboratory tests
17
Replications of Programs
Four curricula initially found to be effective have been implemented multiple times in different
communities by different program staff and evaluated. The rst, which was implemented in four
different studies by three different research teams, consistently delayed sex and sometimes increased condom use.12 The second, when implemented out-of-school in ve different studies, consistently increased condom use and/or improved other sexual risk behaviors;13 it was then implemented in-school but did not have a signicant impact on any sexual behavior there.14 The third,
which was implemented and evaluated in two different studies, had positive effects on multiple
sexual behaviors;15 when greatly shortened, it did not signicantly change behavior.16 The fourth
curriculum had positive effects on condom use when implemented in the community, but when
some of the condom activities had to be removed, it failed to have an impact on condom use.17
18
Overall, the results of these replication studies are quite encouraging, providing evidence that curricula can often be effective when they are implemented as designed by others in different communities. Less clear is whether effective programs will remain effective if 1) they are shortened
considerably, 2) they omit activities that focus on increasing condom use, or 3) they are designed
for and evaluated in community settings but are subsequently implemented in classroom settings.
19
20
Chile
Jamaica
Kenya
Nigeria
South Africa
Belize
Tanzania
Mexico
Kenya
Mexico
Chile
South Africa
Tanzania
Chile
Nambia
Cabezon*
Eggleston
Erulkar
Fawole
Harvey
Kinsler
Klepp
Martinez-Donate
Maticka-Tyndale
McCauley
Murray
Reddy
Ross
Seidman
Stanton
Neg
NS
Pos
Reduce
frequency of sex
Neg
NS
Pos
Reduce number
of partners
Neg
NS
Pos
Increase
condom use
Increase
contraceptive
use
Neg NS Pos
Pos=Positive (desirable) effect on factor; NS=no statistically signicant impact; Neg=negative (undesirable) effect on factor.
*This study by Cabezon measured impact on pregnancy but did not measure any of the behaviors in this table.
Thailand
Baker
Brazil
Antunes
Pos
Zambia
NS
Agha
Neg
Country
Author
Delay sex
Table 3. Eects on Dierent Sexual Behaviors and Outcomes, Reported by Developing Country Studies
Neg
NS
Pos
Reduce sexual
risk-taking
Knowledge
Of the many studies that measured impact on knowledge, most demonstrated that their respective
sex and HIV education programs did increase knowledge about a wide variety of topics involving sexual risk behavior. The evidence is particularly strong that programs increased knowledge
about HIV, STIs, and pregnancy (including methods of preventing them). The evidence is also
strong that programs increased overall knowledge about a variety of sexual topics. Only a small
number of programs failed to increase knowledge about the topics that were measured.
Perceived Risk
Sixteen studies measured impact on perceived HIV risk, and half were effective at increasing
perceived risk of HIV. While many programs strived to increase awareness of HIV risk, if they
actually reduced participants sexual risk behavior, then these programs would logically reduce
their perceived risk and thus possibly negate the positive effects of the programs creating greater
awareness of HIV risk in their communities. Only three studies measured impact on perceived
risk of pregnancy, and they were not effective at changing this perception.
21
Perceived Severity
Eight studies measured perceived severity of the consequences of HIV, other STIs, and pregnancy,
and more than half were effective. More specically, three of four studies found increased perceived severity of HIV/AIDS; only one measured impact on perceived severity of STIs and it was
effective; and two of ve programs were effective at increasing perceived severity of pregnancy.
22
Communication Behavior
More than 20 studies measured impact on reported communication, especially communication
with parents or adults. More than half found improved communication. Four of seven studies
found increased reported communication between participants and their current partner about
AIDS, STIs, and/or past sexual partners. Similarly, eight of 11 programs increased communication between participants and their parents or other adults about sex, condoms, or contraception.
These results demonstrate that it is possible to improve reported communication between youth
and these important individuals in their lives.
Other Behavior
A majority of programs (and a minimum of three programs) found a positive impact on avoiding places and situations that might lead to sex and on obtaining and/or carrying a condom. On
the other hand, of the 11 studies that measured alcohol or drug use, a large majority found no
reduction in use. Moreover, none of the three studies that measured alcohol or drug use before
sex reported any impact. These discouraging results may reect the fact that few, if any, of the
programs placed much emphasis on reducing alcohol and drug use.
Few studies measured the impact of programs on relationships with parents or on psychological
states (e.g., self-esteem or mental health). For those that did, the results were generally mixed.
While the results regarding relationships with parents were typically positive, those for psychological states were typically not signicant.
Overall Impact
The review of studies found strong evidence that many programs can improve knowledge about
HIV, other STIs, pregnancy, and methods of preventing these risks; awareness of risk of HIV;
values and attitudes about sex, condoms, risky sexual behavior, and people living with HIV; selfefcacy to refuse sex and to use condoms; intention to abstain from sex or restrict sex and numbers of partners; and communication with past partners, current partner, and parents. Relevant
knowledge, awareness of risk, values and attitudes, self-efcacy, and intentions are the very factors specied by many psychosocial theories as being the determinants of behavior. Furthermore,
all of these factors have been demonstrated empirically to be related to their respective sexual
behaviors. Thus, it appears highly likely that changes in these factors contributed to the changes
in sexual risk-taking behaviors.
23
Table 4: Number of Programs Having Eects on Mediating Factors that May Aect
Sexual Behavior or Condom or Contraceptive Use
Pos*
NS
Neg
Knowledge
Overall knowledge of sexual issues**
Knowledge of pregnancy
Knowledge of STIs
Knowledge of HIV
Knowledge of abstinence
Knowledge of methods of contraception
Knowledge of condoms
Knowledge of methods to prevent HIV/STIs
Knowledge of community or reproductive health services
Knowledge of ones own sexual limits
7
5
8
28
2
4
5
6
1
1
2
0
3
3
0
2
3
1
1
2
0
0
0
0
0
0
0
0
0
0
Perceived Risk
Perception of pregnancy risk
Perception of STI risk
Perception of HIV risk
0
1
8
3
1
8
0
0
0
1
3
0
1
0
0
14
1
10
0
0
0
14
2
4
5
1
6
1
8
3
3
2
1
0
0
0
0
0
0
0
0
0
**
Pos = Positive (desirable) effect on factor; NS=Not signicant; Neg = Negative (undesirable) effect on
factor.
Lightly shaded factors meet two criteria and therefore have stronger evidence that programs can modify
them: 1) at least three programs signicantly improved them and 2) at least half of the studies that
measured them found signicant improvements.
Table continues on page 25
24
9
4
3
0
13
6
2
1
1
0
0
0
1
0
8
1
12
1
3
3
4
3
4
0
0
0
2
0
1
0
2
2
0
0
1
0
1
1
0
1
0
0
1
2
10
10
0
1
6
4
0
0
0
0
3
0
0
0
0
7
3
2
1
2
1
0
0
0
0
25
Avoiding places and situations that could lead to sex (including pre-coital
sexual activities)
Attending reproductive health clinic
Obtaining and carrying a condom
Putting a condom on partner (females only)
Being tested for STIs
Being tested for HIV
0
3
1
0
0
1
2
0
1
1
0
0
0
0
0
1
2
1
1
0
0
0
1
0
0
0
0
Psychological States
Self-esteem
Depression and mental health
Concern about health
Future orientation
Enjoyment of sex
0
0
0
1
0
1
1
1
0
1
0
0
0
0
0
role. One is the needs, decits, and assets of the youth being served by the program (including
their prior saturation with this topic). The other is the characteristics of the youths environment,
especially the saliency of AIDS, other STIs, or teen pregnancy. All of these factors can affect the
outcome of sex and HIV education programs.
Implementation of the
Curriculum
1. Whenever possible, selected
educators with desired
characteristics and then
trained them
2. Secured at least minimal
support from appropriate
authorities such as
ministries of health, school
districts, or community
organizations
3. If needed, implemented
activities to recruit youth
and overcome barriers to
their involvement (e.g.,
publicized the program,
offered food, or obtained
consent)
4. Implemented virtually all
activities with reasonable
delity
27
or no emphasis was placed on students practicing role plays. In communities that lacked video
equipment, videos and lms were not incorporated. In schools that lacked paper and pencils,
individual worksheets were not used.
5. Pilot-tested some or all activities. Many of the curriculum developers pilot-tested some or all
of the activities and then made modications in the activities before implementing the version
that was actually evaluated. This allowed them to assess what did or did not work.
Curriculum Content
Effective curricula had eight common characteristics. The curricula:
1. Created a safe environment. Virtually all of the effective programs started by creating a set of
ground rules for class involvement, such as not asking personal questions, respecting the right
to refrain from answering questions, recognizing that all questions are legitimate questions, not
interrupting others, respecting the opinions of others, and maintaining the condentiality of
views expressed. Consistent with this, to help youth be more comfortable talking about sexual
topics, some curricula encouraged educators to give positive recognition and positive reinforcement to students questions or comments. In addition, some programs tried to create a safe
environment by separating the class into same-sex groups for certain topics, or by occasionally
limiting the entire course to only one sex.
2. Focused on at least one of three health goals: the prevention of HIV, other STIs, and/or unintended pregnancy. The curricula typically focused on young peoples susceptibility to HIV,
other STIs, and/or pregnancy and the negative consequences of these outcomes. They gave a
clear message about these health goals, namely that if young people have unprotected sex, they
would be likely to contract HIV or another STI or to become pregnant (or cause a pregnancy)
and that there were negative consequences associated with these outcomes. In the process of
doing this, the curricula strived to motivate young people to want to avoid STIs and unintended
pregnancy.
3. Focused narrowly on the specic behaviors that cause HIV, other STIs, or pregnancy and on
the protective behaviors that prevent these outcomes. The curricula designed to prevent HIV
and other STIs focused on abstinence and frequency of sex, number of sexual partners (less
commonly), and condom use. Curricula designed to prevent pregnancy focused on abstinence,
frequency of sex (less commonly), and contraceptive use.
Effective curricula focused on these behaviors in a variety of ways. First, they talked explicitly
about sex, condom use, and contraceptive use. They identied specic situations that might
lead to unwanted sex or unprotected sex and discussed how to avoid these situations and how
to get out of them. They described how to use condoms or contraceptives correctly and how to
overcome barriers for obtaining and using condoms or other forms of contraception. Most of
the effective curricula spent relatively little time talking about broader issues of sexuality, being in love, etc. Only a few related gender roles to sexual or protective behaviors.
Second, effective curricula gave a clear and consistent behavioral message about these sexual
and protective behaviors. Nearly all the effective programs repeated numerous times and in
29
different ways a very clear and consistent message about sexual and contraceptive behaviors.
Most activities in the curricula were designed to change behaviors so that they would be more
consistent with the message. Since most programs were designed to reduce HIV/STIs and
were often designed for sexually experienced youth, the most common message was to use a
condom every time they had sex with any partner. Programs concerned with pregnancy prevention emphasized that young people should use contraception every time they had sex. Several
programs emphasized that abstinence was the safest choice, that unprotected sex was risky, and
that using condoms was safer than unprotected sex.
Although most programs emphasized abstinence and/or condom/contraceptive use, a few
programs recognized that condoms do not provide complete protection against all STIs and
thus encouraged youth to limit their sexual partners, especially older male partners. Programs
in some developing countries, especially Africa, emphasized the dangers of sugar daddies
older men who offer gifts or treats but later want sex in return.
Some programs identied important values in their communities and then appealed to those
values. For example, they repeated be proud, be responsible, or respect yourself. Without
exception, when the programs appealed to these values, they made very clear what sexual and
protective behaviors were consistent with these values.
The messages in these effective programs were appropriate to the age, sexual experience, sex,
and culture of the youth. For example, programs designed for younger youth who were less
likely to be sexually experienced were more likely to place greater emphasis on abstinence
than on condom use, while programs designed for older, more sexually experienced youth were
more likely to place greater emphasis on condom use. A couple of programs for only young
women emphasized that they were capable, powerful and could be in control both generally and more specically in regard to resisting unwanted or unprotected sex and insisting on
condom use.
This particular characteristic of effective curricula appeared to be one of the most important.
Some ineffective curricula provided information, discussed the pros and cons of different
sexual choices, and implicitly let the youth decide what was right for them. In contrast, most of
the activities in effective curricula were directed toward convincing the students that abstaining from sex, using condoms consistently, or using other forms of contraception consistently
was the right choice, and that unprotected sex was clearly an undesirable choice. To the extent
possible, the curricula tried to use group activities to change values, attitudes, and norms about
what was the expected behavior (see next characteristic).
4. Focused on specic sexual psychosocial factors that affect the specied behaviors and
changed some of those factors. Programs designed to reduce sexual activity (i.e., delaying
initiation of sex, reducing the number of partners, or reducing the frequency of sex) focused
on one set of factors, while programs designed to increase condom or contraceptive use tended
to focus on a different but somewhat overlapping set of factors. Many studies did not clearly
specify or did not measure all of the factors they addressed.
The mediating factors below were frequently targeted and were improved. To be on the list, at
least three programs that signicantly reduced reported sexual behavior (or increased reported
30
condom or contraceptive use) had to signicantly improve the mediating factor, and other
research studies must have previously demonstrated that the factor reduced sexual activity (or
increased condom or contraceptive use). At least three programs that reduced sexual activity
and at least three programs that increased condom use focused on and improved the following
factors:
1. Knowledge, including knowledge of sexual issues, HIV, other STIs, and pregnancy (including methods of prevention)
2. Perception of HIV risk
3. Personal values about sex and abstinence
4. Attitudes toward condoms (including perceived barriers to their use)
5. Perception of peer norms and behavior about sex
6. Self-efcacy to refuse sex and to use condoms
7. Intention to abstain from sex or to restrict sex or partners
8. Communication with parents or other adults about sex, condoms, or contraception
In addition, at least three programs that reduced sexual activity focused on and improved:
9. Self-efcacy to avoid STI/HIV risk and risk behaviors
10. Actual avoidance of places and situations that might lead to sex
In addition, at least three programs that increased condom use focused on and improved:
11. Intention to use a condom
Just as some programs that reduced sexual activity also increased condom or contraceptive use,
some programs that reduced sexual behavior also improved mediating factors for condom or
contraceptive use, and vice versa. The fact that programs that reduced sexual activity and programs that increased condom use affected eight of the same mediating factors provides more
evidence that it is possible to do both with the same programs.
5. Included multiple instructionally sound activities to change each of the targeted risk and
protective factors. In order to meet the needs of the targeted young people and to change the selected risk and protective factors, effective programs incorporated multiple activities to change
these factors. Often individual activities were linked to specic factors; others times they addressed multiple factors. These activities employed teaching strategies designed to change each
of the different factors. For example, they used role playing to teach skills to avoid sex.
The particular topics, teaching strategies, and activities used to improve important groups of
risk and protective factors follow:
5A. Basic information about risks of having sex and methods of avoiding sex or using protection. To increase knowledge, the curricula focusing on HIV/STI prevention most commonly
covered modes of HIV/STI transmission, symptoms of STIs, susceptibility to and consequences
of STIs, prevention methods, and related topics. Fewer effective curricula covered testing and
31
treatment of HIV and other STIs. Those covering pregnancy prevention addressed chances of
becoming pregnant if sexually active, consequences of pregnancy, sources of contraception,
and related topics. Various activities were used to convey and help personalize this knowledge,
including short lectures, class discussions, competitive games, simulations (discussed below),
skits, videos, and other techniques. Notably, many of these activities required that the students
obtain and share their information rather than passively listen to the educators.
5B. Perceptions of risk (both susceptibility and severity). Virtually all of the effective curricula
focused on both susceptibility to and severity of HIV/STIs or pregnancy risk. Curricula commonly provided country or local data on the incidence or prevalence of HIV/STIs or pregnancy,
sometimes on youth. These curricula also used class discussions, videos with true stories of
young people having HIV or stories of young people becoming pregnant, handouts, skits, and
other approaches, often involving people similar to the students. Some curricula included activities that further personalized the severity of STIs and pregnancy by asking students to write
a paragraph about how they would feel if they just learned they had contracted HIV or another
STI, or were pregnant (got someone pregnant). The paragraph was also to include what they
could or could not do, both in the short term or in the long term.
5C. Personal values about having sex or premarital sex and perception of peer norms about
having sex. Many programs, especially those for younger youth, promoted abstinence by
repeatedly emphasizing that abstaining from sex was the safest method of avoiding HIV/STIs
and pregnancy. Several programs included group discussions about the advantages and disadvantages of engaging in sex, with educators guiding the discussion so that avoiding sex was
viewed as the best choice by youth. A few curricula discussed methods of showing you care
about someone without engaging in sex. A few included values voting activities in which
youth had to take a position about having sex and then defend it. Several programs provided
data from broader representative surveys or from anonymous class surveys showing that many
youth their age were not having sex and that many peers their age believed their best option
was to avoid having sex at that time. Other activities included talking about ways people use to
get someone to have sex when they may not want to, role-playing activities in which students
practiced saying no to sex, and identication of common situations that might lead to sex.
In the process of discussing and practicing refusal lines and discussing methods of avoiding
situations that might lead to sex, students implicitly conveyed less permissive values and norms
about having sex.
5D. Individual attitudes and peer norms toward condoms and contraception. Effective curricula gave a clear message about using condoms and contraception if sexually active. Typically
they discussed the effectiveness of condoms and contraception, often stating that they did not
provide complete protection against STIs or pregnancy, but that using them was much safer
than unprotected sex. They also stated that condoms provided the only signicant protection
against STIs during sexual activity. Some effective curricula included survey data either from
large samples of youth or from the students in each classroom showing that students believed
that young people should use condoms or contraception if they do have sex.
Effective curricula addressed a variety of attitudes towards condoms and contraception and perceived barriers to using condoms, e.g., perceived effectiveness in preventing STIs and pregnancy,
difculties obtaining and carrying condoms, embarrassment in asking ones partner to use a
condom, the hassle of using a condom, and the loss of sensation while using a condom. These
were addressed by lectures and class discussions that talked about condoms and described their
32
effectiveness if used properly, by discussions about where to obtain condoms with little embarrassment, by visits to drug stores to assess the characteristics of the condoms sold there, by fact sheets
about condoms, and by practicing role plays in which each partner insisted on using condoms.
5E. Both skills and self-efcacy to use those skills. Curricula typically focused on the ability 1)
to refuse unwanted, unintended, or unprotected sex; 2) to insist on using condoms or contraception; and 3) to use condoms correctly. In addition to teaching these skills, a few effective curricula strived to improve general assertiveness skills, ability to obtain condoms or contraception,
and ability to obtain STI testing and treatment. Role playing was used extensively to improve
skills. Many of the curricula rst described the components of the skills verbally, then modeled
them in role plays, and then provided individual practice through role plays in groups of two to
four. Often the role plays started with a plausible scenario for the youth and then followed with
a fully scripted role play in which both actors (the person pressuring to have sex and the person
resisting having sex) simply read scripts. During the role plays in the small groups, the observers used a check list to see if the important components of effective skills were used. Skills
commonly taught included saying no, repeating the refusal, explaining why, using direct
words and appropriate body language, being assertive, using delaying tactics, and others. The
role-playing practice may have both improved the skills and increased the participants condence in their skills. (See box on page 37 for examples of activities that build skills.)
5F. Communication with parents or other adults. Some programs provided homework assignments for participants to discuss selected topics with their parents or other adults. Some provided parents with information about HIV/STIs and pregnancy, adolescent sexual behavior, and
skills to talk more comfortably with their own children about sex. A few curricula described a
variety of values widely held in the communities that parents might wish to emphasize to their
children. Because parents knew that their children were going to have these homework assignments, they could be better prepared and also could understand why their children were asking
questions about sex.
6. Employed instructionally sound teaching methods that actively involved the participants,
that helped participants personalize the information, and that were designed to change each
group of risk and protective factors. The following teaching methods were most commonly
implemented: short lectures, class discussions, small group work, video presentations, stories,
live skits, role plays, simulations of risk, competitive games, forced-choice activities, surveys
of attitudes and intentions with anonymous presentation of results, problem solving activities,
worksheets, homework assignments (including assignments to talk with parents or other adults),
drug store visits, clinic visits, question boxes, hotlines, condom demonstrations, quizzes, and a
variety of other interactive activities.
Nearly all of these instructional methods were interactive and engaged youth; some directly
encouraged youth to apply the concepts to their own lives. The interactive quality of many of
these methods may have helped them change some of the risk and protective factors above that
include much more than knowledge. In addition, consistent with educational theory, the teaching strategies were designed to change their respective risk and protective factors. For example,
to increase perceived risk of contracting STIs, students participated in simulations showing
how rapidly STIs can spread among youth. To change values and norms, students expressed
the advantages of abstaining or using condoms and expressed lines that could be used to refuse
sex. To learn various refusal skills, students practiced role playing.
33
7. Employed activities, instructional methods, and behavioral messages that were appropriate to
the youths culture, developmental age, and sexual experience. Some curricula were designed
for specic racial or ethnic groups and emphasized the high rates of HIV, other STIs, or pregnancy among those groups. The curricula identied the need for young people to be responsible
not only to themselves but also to their communities, by avoiding unprotected sex. Some curricula were designed specically for women and emphasized that women can be powerful and
can be in control in sexual situations. Most curricula were consistent with the developmental
age and sexual experience of the students. Activities for younger youth sometimes included
more basic information, less advanced cognitive tasks, and less difcult activities, while those
for older youth did the reverse. For example, role playing without scripts was more commonly
implemented among older youth than among younger youth. As described above, programs for
younger, less sexually experienced youth focused more on abstinence, while those for older,
more sexually experienced youth focused more on condoms.
8. Covered topics in a logical sequence. In many, but not all, of the curricula, the risk and protective factors and the activities addressing them were presented in a logical sequence. That
sequence often included:
Basic information about HIV/STIs or pregnancy, including susceptibility and severity
Behaviors to reduce vulnerability
Knowledge, values, attitudes, and barriers involving these behaviors
Skills needed to perform these behaviors
Thus, the curricula rst enhanced the motivation to avoid HIV/STIs and pregnancy by emphasizing susceptibility and severity of these events and then addressed the knowledge, attitudes,
and skills needed to avoid them.
Virtually all of the programs trained their educators in the implementation of the curriculum.
This training varied considerably in length and approach. Some of the trainings were based on
skill development and allowed trainees to practice teaching some of the activities; others did not.
2. Secured at least minimal support from appropriate authorities. Virtually all of the effective
programs obtained approval from authorities such as ministries of health or education, school
principals, or directors of local youth-based organizations. This approval may have provided
needed support or sanction for educators who were covering topics that were controversial in
some cultures. It should be noted, incidentally, that all of the programs, whether effective or
not, received some approval, because these were visible research studies that required approval,
often from multiple organizations.
3. Implemented needed activities to recruit youth. If needed, effective programs implemented
activities necessary to recruit youth and avoided or overcame obstacles to their attendance.
For example, if appropriate, they provided program information to youth through schools or
community organizations, provided food and/or other incentives, ensured parental notication, provided transportation, implemented activities at convenient times, and assured safety.
Although this characteristic may be obvious, there are many reported examples in the eld in
which too few youth chose to participate in voluntary sex or HIV education programs, and the
programs were not effective. Some programs also implemented activities for parents to attend.
Often few parents attended these sessions. Typically, programs were more effective at reaching
parents through homework assignments.
4. Implemented curricula with reasonable delity. Most of the effective programs implemented all
or nearly all the activities in the curriculum. Once again, this was in part because these programs were being evaluated through research.
Because some studies provided relatively little information about implementation and also because other studies provided different types of process information (e.g., percentage of activities implemented or distributions of numbers of sessions received by intervention participants),
it was not possible to make a more denitive statement about implementation across all the
studies. On the other hand, the results of the replication studies do provide some information
about the importance of implementation as designed for those few curricula that were evaluated multiple times. As noted above, those studies suggested that intervention may be less
likely to be effective if 1) they are shortened considerably, 2) they omit activities that focus on
increasing condom use, or 3) they are designed for and evaluated in community settings but are
subsequently implemented in classroom settings.
2. Youth volunteered to participate in them. Thus, the youth may have been more open to the
information provided and may not have resented being there. They may have been more open
to behavior change. There also may have been a self-selection bias those who agreed to participate in the study may have been different from those who did not. This self-selection would
not have affected the internal validity of the study, because study participants were randomly
assigned after arriving at the program site, but the self-selection might limit the generalizability
of the ndings.
3. The programs focused primarily on one behavior, typically condom use. This enabled the programs to be more focused, to cover fewer topics, and to give a simpler message.
4. The programs were implemented in small groups of about six or so youth. This enabled the programs to be more efcient. Educators could spend less time managing the classroom and more
time addressing the specic questions and concerns of the individual youth. It also meant that
interactive small group activities could be more easily and more quickly implemented.
Finally, it meant that each group participant could speak up and be involved in discussion a
larger percentage of the time.
36
37
DISCUSSION
This review of 83 studies from developing and developed countries provided important ndings
regarding impact on sexual risk behaviors, changes in mediating factors, and common characteristics of curriculum-based programs that were effective in changing sexual risk behaviors. Other
ndings related to length of impact, replication, type of teacher/leader, and length of intervention.
Research limitations presented challenges in reaching these ndings. Many of the studies of sex
and HIV education programs had methodological aws such as poor evaluation designs, poor
measurement, insufcient statistical power, or failure to measure impact on pregnancy or STI
rates. Also, inherent biases affect the publication of studies researchers are more likely to try
to publish articles if positive results support their theories and programs, and journals are more
likely to accept articles for publication if results are positive. In addition, this review could have
introduced a bias through the process of examining and coding so many signicant research
results (both positive and negative), despite coding rules to reduce this bias. Fortunately, some of
these biases counteract each other. For example, insufcient statistical power partially counteracts
the coding of so many statistical results.
In addition to the research issues, it is important to note that while the characteristics of the curricula their development, content, and implementation affect sexual behaviors of youth, other
factors may also affect these behaviors. These factors include the needs and assets of participating youth and the characteristics of the youths environment, especially the saliency of HIV, other
STIs, and unintended teen pregnancy.
The ndings on program effectiveness were quite robust. The programs were just as likely, if
not more likely, to be effective in developing countries as they were to be effective in developed
countries. They were effective in both urban and rural areas; in both low- and middle-income
communities; and in school, clinic, and community settings. They were also effective with both
advantaged and disadvantaged youth, both males and females, different racial and ethnic groups,
both younger and older youth, and both sexually experienced and inexperienced youth. There is
some indication that they were especially effective with youth who were most likely to engage
in unprotected sex with multiple partners and thus were at highest risk of HIV, other STIs, and
pregnancy.
Given that many programs reduced sexual behavior and/or also increased condom or contraceptive use, they logically would be expected to reduce both STI and pregnancy rates. However, in
general, the results of the few studies that measured impact on STI or pregnancy rates did not
produce many signicant positive effects. This may have been because sample sizes were too
small to detect programmatically meaningful effects or there were other methodological limitations. Also, the changes in behavior may have been too small or too short term to produce marked
changes in STI or pregnancy rates, or perhaps the behaviors that changed were not those that have
the strongest impact on STI rates. While these programs alone cannot solve the problems of STIs,
HIV, and unintended pregnancy, many of them can change sexual and protective behaviors in desired directions, and they can be an important component in larger more comprehensive initiatives.
In addition to the rigorous procedures used to identify these 17 characteristics, other kinds of evidence also demonstrate their importance. For example, several studies involved a comparison of
the impact of skill-based curricula that incorporate all (or nearly all) of these characteristics with
the impact of knowledge-based curricula that did not incorporate many of these characteristics.
Consistently, the skill-based programs were more effective at changing behavior than were the
knowledge-based programs.23
Identifying the 17 common characteristics required both a qualitative and quantitative review of
the available curricula and published studies. However, inadequate published descriptions of the
programs and numerous methodological limitations meant that it was not possible to assess quantitatively the relative importance of each of the 17 characteristics.
Other Findings
Long term impact. At least 10 interventions had long term effects lasting two or more years; some
lasted for close to three or more years as long as the effects were measured. These interventions
were typically implemented in schools, had sequential curriculum activities that were implemented for at least two years, and had either additional school curriculum activities or schoolwide activities that extended into subsequent years. These results suggest that having sequential
curriculum activities over multiple years may enhance long term impact.
Age of educators. While both adult-led and peer-led programs have been found to be effective, the
evidence is stronger that adult-led programs are effective, in part because there have been more
studies of these programs. Some effective programs were taught by adults but used peer educators
to help with various classroom and school-wide activities.
Length of intervention. There were wide variations in the length of the interventions, in terms of
number of sessions and number of hours. A few very short programs were also effective, provided
that 1) they were implemented after school or on weekends when participants were fresher, 2)
they were implemented in small groups, and 3) youth volunteered to participate (and may have
been more open to change).
Replication. When three programs were replicated carefully in different locations in the United
States but in the same type of setting, the original positive effects were conrmed. This is encouraging and suggests that effective programs can remain effective when they are implemented
by other people in other communities. However, when curricula were shortened, when important
activities were removed, or when a program originally implemented among volunteer youth in a
community setting was then implemented among students in the classroom, the positive changes
in behavior were not always replicated. These ndings reinforce the importance of implementing
effective programs as designed.
40
RECOMMENDATIONS
The results and discussion sections lead to recommendations in areas of programmatic implementation and future research designs.
Programmatic Recommendations
First and foremost, communities should implement curriculum-based sex and HIV education
programs in their schools, clinics, and youth-serving agencies. To the extent possible, organizations should either: 1) implement as designed specic curricula that have already been demonstrated to be effective with populations and in cultures similar to their own or 2) implement or
adapt programs that incorporate as many of the effective curriculum characteristics as possible.
If organizations develop their own curriculum or adapt existing ones, then they should strive to
create curricula that incorporate as many of the eight content characteristics as possible. During
their process of developing their own curricula, they should also: 1) include multiple individuals with expertise in different areas in the design of the curriculum, 2) assess the needs and
assets of the young people they are targeting, 3) develop a logic model for the curriculum, 4)
design activities consistent with community values and resources available, and 5) pilot-test and
revise the activities.
When organizations implement programs, they should select educators who have desired characteristics, train them, secure any needed support from appropriate authorities, assure adequate
recruitment of youth, and implement the curricula as designed.
The issues of pregnancy and STI/HIV prevention are most salient among high-risk youth in
the highest risk areas; some programs may have had their greatest impact in these areas. Thus,
while programs should reach all youth, they should be especially certain to reach high-risk
youth.
Schools and youth-serving organizations should provide adequate time in the classroom or in
their organizations for these programs. Organizations should also provide both training and support so that educators can implement effective programs as designed.
Organizations should encourage and facilitate research to develop and evaluate programs that
may be even more effective. This will help advance the eld.
Communities should not rely solely on these programs to address problems of HIV, other STIs,
and pregnancy, but should view these programs as a component that can reduce sexual risktaking behavior to some degree and can contribute to long term success in efforts to reduce
rates of HIV, other STIs, and unintended pregnancy among young people.
Research Recommendations
Rigorous program evaluation is critical to the improvement of pregnancy and HIV prevention
programs for youth. Findings from this review have several implications for how program evaluations can produce the most meaningful ndings.
41
Conclusion
In summary, enormous progress has been made in the development of effective sex and HIV
education programs. About 20 years ago, no programs had demonstrated signicant changes in
behavior; by now a large majority have done so, and a few have even demonstrated a positive
impact for three years or more. Today one important challenge is to develop programs that not
only reduce sexual risk-taking behavior, but also signicantly reduce HIV and STI transmission
and unintended pregnancy. Five programs have accomplished that; more need to follow, and they
undoubtedly will. And a second important challenge is to implement far more broadly those programs with strong evidence of behavioral change or at the very least, to implement programs that
incorporate the 17 characteristics found to be common among effective curricula. This is beginning to happen, but much more effort should be devoted to it.
42
43
ENDNOTES
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2 FOCUS on Young Adults, Advancing Young Adult Reproductive Health: Actions for the Next Decade. Washington
D.C.: Pathnder, 2001; Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy.
Washington DC: The National Campaign to Prevent Teen Pregnancy, 2001.
3 Kirby D, Short L, Collins J, et al. School-based programs to reduce sexual risk behaviors: a review of effectiveness.
Public Health Reports 1994;109(3):339-60.
4 Kirby D, Short L, Collins J, et al.
5 Sonenstein FL. Measuring sexual risk behaviors. Paper presented at a meeting of the American Enterprise Institute
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6 Plummer ML, Ross DA, Wight D, et al. A bit more truthful: the validity of adolescent sexual behaviour data
collected in rural northern Tanzania using ve methods. Sex Transm Infect 2004;80(Suppl 2):ii49-56.
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Mwanza, Tanzania. London, England: London School of Hygiene and Tropical Medicine, 2003.
8 Kirby D, Baumler, E, Coyle KK, et al. The Safer Choices intervention: its impact on the sexual behaviors of
different subgroups of high school students. J Adolesc Health 2004;35(6):442-52.
9 St. Lawrence JS, Crosby RA, Braseld TL, et al. Reducing STD and HIV risk behavior of substance-dependent
adolescents: a randomized controlled trial. J Consult Clin Psychol 2002;70(4):1010-21.
10 Ross.
11 Coyle KK, Basen-Engquist KM, Kirby DB, et al. Safer Choices: reducing teen pregnancy, HIV and STDs. Public
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12 Kirby D, Barth RP, Leland N, et al. Reducing the risk: impact of a new curriculum on sexual risk-taking. Fam
Plann Perspect 1991;23(6):253-63; Hubbard BM, Giese ML, Rainey J. A replication of Reducing the Risk, a theorybased sexuality curriculum for adolescents. J Sch Health 1998;68(6):243-47; Zimmerman R, Cupp PK, Hansen
GL, et al. The Effects of a School-based HIV and Pregnancy Prevention Program in Rural Kentucky. Lexington,
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Driven HIV and Pregnancy Prevention Curriculum. Lexington, KY, University of Kentucky, nd.
13 Jemmott JB III, Jemmott LS, Fong GT. Reductions in HIV risk-associated sexual behaviors among black male
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for young African-American adolescents. JAMA 1998;279(19):1529-36; Jemmott JB III, Jemmott LS, Fong GT, et
al. Reducing HIV risk-associated sexual behaviors among African American adolescents: Testing the generality of
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Intervention for Latino Youth, Ann Arbor, MI, University of Michigan School of Nursing, nd.
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